Authorization to Release Veterinary Records

You can submit this form in three different ways:

Download, print and fax us the “Authorization to Release Veterinary Records PDF Form” to (830) 393-6550
Download, print and email us the “PDF Form” to deasonah1990@yahoo.com
Fill out the digital form below:

Marked Fields are Required [*]

Please make a selection:(Required)

I would like to authorize Deason Animal Hospital to OBTAIN my pet’s records from another veterinarian

I would like Deason Animal Hospital to RELEASE my pet’s records to another hospital

Authorized Agent (Owner)(Required)

First Last

Patient Name(Required)

Current Veterinarian Info

Records are being requested to establish a full health history for an upcoming appointment with us at Deason Animal Hospital, 1712 D St. Floresville, TX 78114 Fax (830) 393-6550 or deasonah1990@yahoo.com For any questions, concerns, or issues; please call (830) 393-4567.

Hospital Name(Required)

Hospital Address(Required)

Street Address Address Line 2 City State ZIP Code

Hospital Phone(Required)

Hospital's Email

Hospital's Fax #

Release my Pet's Records

Deason Animal Hospital will release your pet’s records to the following veterinary practice:

Hospital Name(Required)

Hospital Address(Required)

Street Address Address Line 2 City State ZIP Code

Hospital Phone(Required)

Hospital Email

Hospital Fax

Additional Information

Please send the Patient’s(Required)

Vaccination Records

Full Medical History

X-Rays

Lab Work

I release the Veterinarian and staff members from any legal responsibility and liability or the release of information to the extent indicated as authorized herein. For any questions, concerns, or issues; please call (830) 393-4567.(Required)

I agree and accept

Client Identifying Information

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Email(Required)

Client ID Number

Patient Identifying Information

Name(Required)

Gender(Required)

D.O.B.(Required)

Breed(Required)

Client Signature

Date

This field is for validation purposes and should be left unchanged.